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Problematic Cost–Utility Analysis of Interventions for Behavior Problems in Children and Adolescents

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DOI: 10.1002/cad.20360

R E V I E W

Problematic cost–utility analysis of interventions for behavior problems in children and adolescents

  • Marinus H. van IJzendoorn1,2
  • Marian J. Bakermans-Kranenburg3

1 Erasmus University Rotterdam, Rotterdam, The Netherlands

Abstract

Cost–utility analyses are slowly becoming part of randomized control trials evaluating physical and mental health treatments and (preventive) interventions in child and adolescent development. The British National Institute of Health and Care Excellence, for example, insists on the use of gains in Quality Adjusted Life Years (QALYs) to compute the “value for money” of interventions. But what counts as a gain in quality of life? For one of the most widely used instruments, the EuroQol 5 Dimensions scale (EQ-5D), QALYs are estimated by healthy individuals who provide utility scores for specific health states, assuming that the best life is a life without self-experienced problems in five domains: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. The worst imaginable outcome is defined as “a lot of problems” in each of these five domains. The impact of the individual’s problems on the social network is not weighted, and important social–developmental domains (externalizing problems, social competence) are missing. Current cost– utility computations based on EQ-5D favor physical health over mental health, and they rely on adult weights for child and adolescent quality of life. Thus, a level playing field is absent, and developmental expertise is sorely missing.

2 University of Cambridge, Cambridge, UK 3 Vrije Universiteit Amsterdam, Amsterdam, The Netherlands

Correspondence

Marinus H. vanIJzendoorn, ErasmusUniversity, Rotterdam, Netherlands.

Email:[email protected]

Fundinginformation

TheEuropeanResearchCouncil;theDutch MinistryofEducation, Culture, andScience; theNetherlands OrganizationforScientific Research(NWOgrant number024.001.003)

K E Y W O R D S

cost-utility analysis, interventions, children, mental health, Quality Adjusted Life-Years (QALY), EuroQol 5 Dimensions scale (EQ- 5D), critical review

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

© 2020 Wiley Periodicals LLC

Child & Adolescent Development. 2020;2020:89–102.

wileyonlinelibrary.com/journal/cad

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For policy advisers and politicians, health economics is increasingly important because of cost–utility analyses of randomized control trials (RCTs) on mental health problems. A crucial question is whether and when they are willing to pay the price of investment in child and adolescent interventions. In particular, we focus here on the costs of interventions aiming at behavior problems and lack of social competence in return for benefits enjoyed by children, their parents, and society. In its report on “Judging whether public health interventions offer value for money” the National Institute of Health and Care Excellence (NICE, 2018) in the United Kingdom, for example, recommends the use of Quality Adjusted Life Years or QALYs to compute the value for money of interventions. In health economics, other approaches have been developed to estimate costs and benefits of interventions, and the willingness to pay for a treatment, for example, the Disability Adjusted Life Year or DALY approach (e.g., McBain et al., 2016) but they are beyond the scope of the current paper (see Drummond, Sculpher, Claxton, Stoddart, & Torrance, 2015, for other methods). In this paper, we discuss the scientific, normative, and developmental assumptions of one of the most widely used health economics models as currently applied to child and adolescent (preventive) intervention programs. The EuroQol 5 Dimensions scale (EQ-5D) used to retrieve the utility scores to compute QALYs is taken as an example to illustrate the challenges of a predominant health economics approach. Health economics is an emerging field of inquiry that cannot be left to economists alone. Developmental science expertise should be brought to bear on the premises, measurements, and analyses in cost–utility computations, lest children, adolescents, and their families suffering from mental health issues pay the price.

  • 1
  • COST–UTILITY ANALYSIS

Cost–utility analysis is often defined as the evaluation of “the impact of the intervention in terms of improvements in preference-weighted health-related quality of life, such as the Quality Adjusted Life Year (QALY)” (Beecham, 2014; p. 715). A basic idea is that it is possible to create one common yardstick or generic currency across all health-related interventions. The QALY would be such a currency: the gold standard against which any health-related intervention in any clinical or at-risk group could be measured, allowing decision-makers to select the prevention or intervention program with the best cost/quality ratio. Based on QALY, it would even be possible to weight the best value for money of medical treatments against that of mental health interventions, a truly interdisciplinary ambition.
The idea behind QALY was introduced in a paper by Klarman, Francis, and Rosenthal
(1968) on the advantages of transplantation versus dialysis in patients with renal failure (see also MacKillop & Sheard, 2018). In this paper Klarman not only took into account the number of years of life added by each of the treatments, but also the quality of these extra years of life after transplantation, which was estimated to be 25% better than with dialysis. In QALY, the combination of quantity (mortality) and quality (morbidity) of life years is the core of the computation. It is evident that patients experience life after transplantation as “better,” compared to life with regular dialysis. But how did Klarman et al. (1968) arrive at the 25% quality bonus? In this case, they just assumed without any further theoretical or empirical evidence that the extra life quality could be quantified as one quarter of each life year gained.

  • 1.1
  • Creating a gold standard for quality of life

A more sophisticated way to estimate quality of life has been developed by assessing patients’ or non-patients’ preferences for a shorter life without health issues, versus a

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T A B L E 1 Time trade-off (TTO) weights for the various health states represented by EuroQol 5 Dimensions Scale (EQ-5D) to compute quality adjusted life years (QALYs)

Mobility

.069

Self-care

.104

Activity

.036

Pain

.123 .386

Depression

  • .071
  • Some problems

  • A lot of problems
  • .314
  • .214
  • .094
  • .236

Constant .081; malus for “a lot of problems” −.269. Weights derived from Dolan et al. (1995).

longer life with health problems lowering the quality of the extra years. The preferences are established on the basis of a generic measure of quality of life that covers various domains of functioning such as physical, mental, and social functioning. For example, the widely used instrument EQ-5D (see EuroQol, 2020) comprises five questions, covering five dimensions, that is, physical mobility, looking after yourself, doing usual activities, having pain or discomfort, and feeling anxious or depressed. In the EQ-5D-Y (Youth version; see EuroQol, 2020), the questions have been slightly adapted, using, for example, the terms worried, sad, or unhappy instead of anxious or depressed. Each dimension has three levels corresponding to (1) “no problems,” (2) “some problems,” and (3) “a lot of problems.” The various health states are indicated by one of the three scores on the five dimensions (e.g., if the respondent indicates to experience a lot of problems in the first dimension, mobility, and some depressive problems but no problems in the other dimensions, the health state is represented as 31112. In an updated measure, the EQ-5D-5L (see EuroQol, 2020), the same five dimensions are used with more differentiated response alternatives (no, slight, moderate, severe, and extreme). Validation of this revized measure is underway but, currently, NICE still recommends the three-level utility estimates as a basis for computing QALYs.
One way to establish preferences or utilities for each of the various health states is to survey a large representative sample asking the respondents to choose between extra life years with the impairments in each of these dimensions (t) and a shorter life without any problems on these dimensions (x). This time trade-off (TTO) approach results in a preference or utility score for the impaired status of x/t. In other words, the respondents are asked to indicate the number of years in full health that they consider equivalent to 10 years in a specific impaired state (e.g., with a lot of problems in the mobility dimension and some problems with depression, state 31112). When a respondent considers 6 years in full health equivalent to 10 years with a lot of mobility problems and some depressive problems, the respondent’s weight for this state would be 6/10. Based on a sample of respondents answering the same question their average opinion is the weight for that state of (ill) health which subsequently is used to compute the QALY. The approach fits the traditional economic model of the “homo economicus” who is a rational respondent with preferences (or utilities) with the goal to maximize these individual, self-interested preferences (Melé & Cantón, 2014).

  • 1.2
  • From full health to death

In fact, the weights are rankings on a continuum from zero (death; state 33333) to one (full health; state 11111). In a UK representative sample of 2,997 non-clinical adult participants, Dolan, Gudex, Kind, and Williams (1995) used the TTO approach to valuate the various states. The participants showed their preferences (utilities) for a large number of states, which resulted in coefficients for levels 2 (some problems) and 3 (a lot of problems), respectively, for each of the domains, see Table 1. The algorithm is completed with a constant: .081, and a “malus” of −.269 when one or more score of 3 (a lot of problems) on

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any dimension is given. Dolan et al. (1995) calculated the constant as the intercept of the regression equation that is at the basis of the computation of utilities for the various health states, and it indicates any deviation from perfect health. The malus is also a constant that Dolan et al. (1995) included in the regression equation to avoid the residuals to be associated with the predicted values. The relevant weights for a specific state are subtracted from the state of full health in all domains. Thus, state 11111 amounts to a weight of .919 (the constant .081 subtracted from 1), and the weight for the worst state 33333 (“death”) amounts to −.594. About one third of all health states receive weights lower than 0 (Devlin, Shah, Feng, Mulhern, & Van Hout, 2018).
This approach leads to “social tariffs” for each condition or health state, and these tariffs are being used in health economics studies across the world and for every age cohort since 25 years (e.g., Goodyer et al., 2017). The state indicated by 31112, for example, gets the QALY weight of 1 − .081 − .314 − 0.000 − .000 − .000 − .071 − .269 = .265. Once the weights for each response category and the social tariffs for each health state are established in a large survey like Dolan et al. (1995)’s study, participants in a RCT can be asked to answer the five questions, and the QALYs for each of the subjects can be computed. If participants after treatment or intervention find themselves in a health state that is higher (closer to full health) than participants in the control group who received care as usual, the intervention is considered to be better than care as usual. The expenses for the intervention compared to care as usual can be summarized and cost per QALY gain is computed. Interventions with lower cost per QALY gain will in general be preferred above those with higher costs—assuming sufficiently replicated evidence for robust positive effects of the preferred intervention.
The QALYs are thus generic in the sense that they can be used for the evaluation of any treatment or intervention in the developmental, social, psychological, medical, psychiatric, clinical, or preventive domain because the five dimensions pretend to cover the whole gamut of components of the “good life” (Drummond et al., 2015). In principle, all health-related interventions and treatments could be listed in one ranking of more to less value for money (Dixon & Welch, 1991). It should be noted that because no valuation for the child and adolescent EQ-5D-Y has yet been conducted (https://euroqol.org/eq-5d- instruments/eq-5d-y-about/valuation/) the weights assigned to each state of child or adolescent health are currently the same as the adult weights, although considerable doubts about this generalization can, and have been raised (Kind, Klose, Gusi, Olivares, & Greiner,

2015).

The Child Health Utility-9 Dimensions scale (CHU-9D) with nine questions covers a somewhat broader range of functioning (worry, sadness, pain, tiredness, annoyance, school, sleep, daily routine, and activities; Furber & Segal, 2015) but similar to the EQ-5D-Y it also lacks externalizing and social competence dimensions. The CHU-9D seems more tailored to adolescent development than the EQ-5D-Y, although adult tariffs for CHU-9D have often been used (Stevens, 2012). An additional issue is that the reliability and construct and convergent validity of the CHU-9D scores seem rather modest (Stevens, 2012). Here we focus on the EQ-5D-Y, but developmental analysis of the CHU-9D approach is critically needed.

  • 1.3
  • QALY as the gold standard

QALY has become the gold standard in health economics and policy, in the UK as well as in other Western countries. The report on “Judging whether public health interventions offer value for money” (NICE, 2018) considers an intervention good value for money if the

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  • MEDLINE
  • Web of Science
  • Current Contents SciELO Citation Index

Records excluded n=58 *no empirical study
Records screened n=82
Records excluded n=10: • Not about mental health; • Overlapping sample other paper;
• No usuable data; • Review or meta-analysis;
Full text searched and assessed for eligibility n=24

Included in the review n=14

F I G U R E 1 Flow chart of the literature search of randomized control trials focusing on infant or child mental health issues using health economics, in particular the QALY approach

cost of an intervention that manages to create one QALY gain is less than £30,000. It is argued that in any society the budget for health-related interventions will be limited, scarce resources have to be distributed, and budget constraints will be set by politicians. Within these budget limits policy makers might feel obliged to choose an evidence-based treatment for depressive adults of £10,000 per QALY gain, instead of a preventive intervention reducing emerging conduct problems in children for £12,000 per QALY gain. A childhood intervention for post-traumatic stress symptoms that would cost £50,000 per QALY gain would not be fundable except when policy makers want to take into account other than only budgetary considerations such as a strong patient lobby or firm public opinion about the need for such an intervention.
It should be noted that weights for the various states might differ between countries, even when they are neighboring countries with rather similar cultures. For example, in one of the few countries with their own weights, the Netherlands, respondents assign more weight to the depression and anxiety dimension compared to the UK participants, and less weight to the other dimensions (Lamers, McDonnell, Stalmeier, Krabbe, & Busschbach, 2006). No utility scores for computation of QALYs are available from valuation studies in most lower and middle income countries (LMICS). In these countries the DALY approach is more often used (e.g., McBain et al., 2016). The World Health Organization recommends the DALY method for LMICS interventions, defining a DALY as one lost year of “healthy”

life (https://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/). Because

DALYs have major impact on policy decisions in LMICS, cross-cultural anthropological and sociological knowledge about child and adolescent development acquired in the developmental sciences is critically needed. Here we limit ourselves to the QALY approach.

  • 2
  • CHILD AND ADOLESCENT MENTAL HEALTH ECONOMICS IN

PRACTICE

In order review to how the cost–utility analysis has been applied in intervention studies on child and adolescent mental health we searched in Web of Science, Current Contents, Medline, and SCIELO for empirical papers presenting RCTs focusing on infant or child

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van IJZENDOORN and BAKERMANS-KRANENBURG

mental health issues using health economics, in particular the QALY approach. Search terms were (“cost-effectiveness” or “cost-utility” or QALY or “health economics”) AND (infan* or child*) AND (“mental health” or “behavior problem*”) AND (“randomised trial*”). The search terms for mental health and behavior problems are quite broad and treatments targeting a specific disorder might not have been included. We focused on the most common issues and interventions. Figure 1 presents the search (k = 14 studies; March 3, 2020).
The use of QALYs in economic analyses of mental health interventions is relatively recent, and only a small proportion of randomized control trials present a cost–utility analysis. But the number of pre-registered protocols for RCTs which include a health economics component is growing. In the past 7 years, 14 RCTs on child and adolescent mental health analyzed cost–utility or value for money. The studies are summarized in Table 2. From Table 2 it may be derived, for example, that the Canaway et al. (2019) school-based intervention program “Waves” targeting obesity required an investment of 155 pounds per child (ages ranging from 6 to 7 years.) and that this intervention resulted in .006 QALY gain. The incremental cost-effectiveness ratio (ICER) thus amounted to 26,815 pounds. The QALY gain calculation was based on the CHU-9D and the cost-effectiveness of Waves can now be compared with any other intervention targeting obesity or any other (mental) health issue. Most randomized trials were group based, and focused on adolescents with internalizing issues such as depression, anxiety, insomnia, obesity, and PTSD (e.g., Canaway et al., 2019; Robertson et al., 2017). In most studies, the intervention or treatment was compared to care as usual (e.g., Ougrin et al., 2018; Simkiss et al., 2013; Turner, Carter, Sach, Guo, & Callaghan, 2017), but some studies compared two or more different treatments (e.g., Chatterton, Rapee, & Catchpool, 2019; Creswell et al., 2017; De Bruin, Van Steensel, & Meijer, 2016; Sayal et al., 2016).
QALY assessments were conducted with the EQ-5D and the CHU-9D. One study used the mapping of the Strengths and Difficulties Questionnaire (SDQ) on CHU-9D to get utility weights (see Section 3.7 (Shearer et al., 2018). The primary outcome effects of most studies were non-significant, as were the effects on QALYs, with the exception of one trial on the effectiveness of cognitive therapy for PTSD (Shearer et al., 2018). In four trials, negative QALY effects were found (Anderson et al., 2014; Barnes et al., 2017; Goodyer et al., 2017; Sayal et al., 2016). It is difficult to see the relevance of a cost–utility analysis in the absence of a QALY gain of the intervention, except maybe when a small negative effect is outweighed by much lower expenses compared to care as usual. From an ethical perspective, an intervention that lowers quality of life might be considered iatrogenic compared to care as usual, and thus inadmissible even with cost savings.
The incremental cost-effectiveness ratio (ICER) for most of these interventions was above conventional criteria for willingness to pay (£20,000–30,000). This is a bleak picture of the cost–utility in a set of 14 recent randomized trials aimed at improving mental health of children and adolescents. This is even more remarkable when the relatively low added costs for the interventions is taken into account, with most of the interventions costing less than £1,000. Furthermore, most interventions were implemented on the group level, and interventions on the individual level will almost always be costlier. This implies that individual treatments will tend to present even more negative ICERs, unless they are much more effective. In this set of trials, QALY gains seem small. Largest gains might be produced by interventions focusing on one severe handicap: When an intervention manages to lower the severity of this handicap from 3 (a lot of problems) to 2 (some problems) with everything else remaining equal, this would computationally mean that the malus of −.269 would turn into a bonus of .269. The downside is that (preventive) interventions aiming at reducing “some” problems in most or all domains would automatically show

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    Attachment at an Early Age (0-5) and Its Impact on Children’S Development Marinus Van Ijzendoorn, Phd Erasmus University Rotterdam, Netherlands September 2019, Rev

    ATTACHMENT Attachment at an Early Age (0-5) and its Impact on Children’s Development Marinus van IJzendoorn, PhD Erasmus University Rotterdam, Netherlands September 2019, Rev. ed. Introduction What is attachment? Children are considered to be attached if they tend to seek proximity to and contact with a 1 specific caregiver in times of distress, illness and tiredness. Attachment to a protective caregiver helps infants to regulate their negative emotions in times of stress and distress and to explore the environment, even if it contains somewhat frightening stimuli. Attachment, a major developmental milestone in the child’s life, remains an important issue throughout the lifespan. In adulthood, attachment representations shape the way adults feel about the strains and stresses of intimate relationships, in particular parent-child relationships, and the way in which the self is perceived. Development of attachment 1 Attachment is suggested to develop in four phases. In the first phase — indiscriminately orienting and signalling to people — the baby seems “tuned” to certain wave-lengths of signals from the environment. These signals are mostly of human origin (e.g. the sound of voices). During the second phase, probably first by smell and then by sight, the baby develops preference for one or more caregivers — the phase of orienting and signalling to one or several specific persons. Not until the infant is able to show active attachment behaviour, such as actively seeking proximity to and following the attachment figure, does the infant enters the third phase, the phase of attachment proper — staying near a specific person by means of signalling and movement.
  • International Journal of Behavioral Development

    International Journal of Behavioral Development

    International Journal of Behavioral Development http://jbd.sagepub.com/ Impact of institutional care on attachment disorganization and insecurity of Ukrainian preschoolers: Protective effect of the long variant of the serotonin transporter gene (5HTT) Marian J. Bakermans-Kranenburg, Natasha Dobrova-Krol and Marinus van IJzendoorn International Journal of Behavioral Development published online 17 June 2011 DOI: 10.1177/0165025411406858 The online version of this article can be found at: http://jbd.sagepub.com/content/early/2011/06/15/0165025411406858 Published by: http://www.sagepublications.com On behalf of: International Society for the Study of Behavioral Development Additional services and information for International Journal of Behavioral Development can be found at: Email Alerts: http://jbd.sagepub.com/cgi/alerts Subscriptions: http://jbd.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav >> Version of Record - Jun 17, 2011 What is This? Downloaded from jbd.sagepub.com at Universiteit Leiden \ LUMC on October 6, 2011 International Journal of Behavioral Development 1–8 Impact of institutional care on ª The Author(s) 2011 Reprints and permissions: attachment disorganization and sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0165025411406858 insecurity of Ukrainian preschoolers: ijbd.sagepub.com Protective effect of the long variant of the serotonin transporter gene (5HTT) Marian J. Bakermans-Kranenburg,1 Natasha Dobrova-Krol,1 and Marinus van IJzendoorn1 Abstract Institutional care has been shown to lead to insecure and disorganized attachments and indiscriminate friendliness. Some children, however, are surprisingly resilient to the adverse environment. Here the protective role of the long variant of the serotonin receptor gene (5HTT) is explored in a small hypothesis-generating study of 37 Ukrainian preschoolers reared in institutional settings or in their biological families.
  • IX. RESEARCH, PRACTICE, and POLICY PERSPECTIVES on ISSUES of CHILDREN WITHOUT PERMANENT PARENTAL CARE Robert B

    IX. RESEARCH, PRACTICE, and POLICY PERSPECTIVES on ISSUES of CHILDREN WITHOUT PERMANENT PARENTAL CARE Robert B

    MONOGRAPHS OF THE SOCIETY FOR RESEARCH IN CHILD DEVELOPMENT IX. RESEARCH, PRACTICE, AND POLICY PERSPECTIVES ON ISSUES OF CHILDREN WITHOUT PERMANENT PARENTAL CARE Robert B. McCall This chapter presents conclusions, trends, conceptual analyses, hypotheses, and speculations regarding some fundamental issues of research, practice, and policy that are largely unsettled or controversial. As such, the chapter is not a summary of Chapters I–VIII, but rather contains interpretations and opinions of the author intended to elevate the priority of certain issues, suggest hypotheses to be studied, and propose practice and policy steps to be considered. This chapter is primarily aimed at presenting conclusions, trends, con- ceptual analyses, hypotheses, and speculations regarding some fundamental research, practice, and policy issues that are unsettled or controversial. The goal is to examine some of the conceptual forests at a time when the field may be preoccupied with individual trees, raise the priorities of these gen- eral issues on future agenda, and heuristically contribute ideas that may be researched or discussed with greater vigor in the future. Thus, this chapter is not a summary of Chapters I–VIII; some points made in those chapters are highlighted here, but additional material is added, some of which was pre- pared for this project and is still unpublished, and a variety of new issues are raised. The interpretations and opinions expressed are those of the author, not a consensus of project participants. SOCIAL SCIENCE ISSUES—A TOUGH SCIENTIFIC NUT TO CRACK Early adversities, whether poverty, malnutrition, abuse and neglect, in- stitutionalization, or other atypical circumstances, represent unfortunate This paper is supported in part by grant HD050212 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development to the author and Christina J.
  • Research Review: Genetic Vulnerability Or Differential Susceptibility in Child Development: the Case of Attachment

    Research Review: Genetic Vulnerability Or Differential Susceptibility in Child Development: the Case of Attachment

    Journal of Child Psychology and Psychiatry 48:12 (2007), pp 1160–1173 doi:10.1111/j.1469-7610.2007.01801.x Research Review: Genetic vulnerability or differential susceptibility in child development: the case of attachment Marian J. Bakermans-Kranenburg and Marinus H. van IJzendoorn Centre for Child and Family Studies, Leiden University, The Netherlands Gene–environment interactions interpreted in terms of differential susceptibility may play a large part in the explanation of individual differences in human development. Reviewing studies on the behavioral and molecular genetics of attachment, we present evidence for interactions between genetic and envir- onmental factors explaining individual differences in attachment security and disorganization. In particular, the DRD4 7-repeat polymorphism seems associated with an increased risk for disorganized attachment, but only when combined with environmental risk. Gene–environment (G · E) interactions may be interpreted as genetic vulnerability or differential susceptibility. We found support for the differential susceptibility hypothesis predicting not only more negative outcomes for susceptible children in unfavorable environments, but also positive outcomes for susceptible children in favorable environments. Keywords: Attachment, gene–environment interaction, differential susceptibility, disorganized attachment, dopamine, behavior problems, genetics. Attachment theory is an important theoretical Hesse, 1999). Maternal sensitivity, however, framework for studying infant–parent relationships accounts for only a third of the association between and individual differences in emotion regulation. parental attachment representation and infant Attachment is the evolutionary-based, innate attachment security, leaving a transmission gap of predisposition of a child to seek proximity to and unexplained variance in infant attachment security contact with a specific figure, notably when the child (Van IJzendoorn, 1995; Belsky, 2005).
  • Disorganized Attachment in Infancy: a Review of the Phenomenon and Its Implications for Clinicians and Policy-Makers

    Disorganized Attachment in Infancy: a Review of the Phenomenon and Its Implications for Clinicians and Policy-Makers

    Attachment & Human Development ISSN: 1461-6734 (Print) 1469-2988 (Online) Journal homepage: https://www.tandfonline.com/loi/rahd20 Disorganized attachment in infancy: a review of the phenomenon and its implications for clinicians and policy-makers Pehr Granqvist, L. Alan Sroufe, Mary Dozier, Erik Hesse, Miriam Steele, Marinus van Ijzendoorn, Judith Solomon, Carlo Schuengel, Pasco Fearon, Marian Bakermans-Kranenburg, Howard Steele, Jude Cassidy, Elizabeth Carlson, Sheri Madigan, Deborah Jacobvitz, Sarah Foster, Kazuko Behrens, Anne Rifkin-Graboi, Naomi Gribneau, Gottfried Spangler, Mary J Ward, Mary True, Susan Spieker, Sophie Reijman, Samantha Reisz, Anne Tharner, Frances Nkara, Ruth Goldwyn, June Sroufe, David Pederson, Deanne Pederson, Robert Weigand, Daniel Siegel, Nino Dazzi, Kristin Bernard, Peter Fonagy, Everett Waters, Sheree Toth, Dante Cicchetti, Charles H Zeanah, Karlen Lyons-Ruth, Mary Main & Robbie Duschinsky To cite this article: Pehr Granqvist, L. Alan Sroufe, Mary Dozier, Erik Hesse, Miriam Steele, Marinus van Ijzendoorn, Judith Solomon, Carlo Schuengel, Pasco Fearon, Marian Bakermans- Kranenburg, Howard Steele, Jude Cassidy, Elizabeth Carlson, Sheri Madigan, Deborah Jacobvitz, Sarah Foster, Kazuko Behrens, Anne Rifkin-Graboi, Naomi Gribneau, Gottfried Spangler, Mary J Ward, Mary True, Susan Spieker, Sophie Reijman, Samantha Reisz, Anne Tharner, Frances Nkara, Ruth Goldwyn, June Sroufe, David Pederson, Deanne Pederson, Robert Weigand, Daniel Siegel, Nino Dazzi, Kristin Bernard, Peter Fonagy, Everett Waters, Sheree Toth, Dante Cicchetti, Charles H Zeanah, Karlen Lyons-Ruth, Mary Main & Robbie Duschinsky (2017) Disorganized attachment in infancy: a review of the phenomenon and its implications for clinicians and policy-makers, Attachment & Human Development, 19:6, 534-558, DOI: 10.1080/14616734.2017.1354040 To link to this article: https://doi.org/10.1080/14616734.2017.1354040 © 2017 The Author(s).
  • Marinus Van Ijzendoorn, Phd, Leiden University, Países Bajos Índice De Contenidos

    Marinus Van Ijzendoorn, Phd, Leiden University, Países Bajos Índice De Contenidos

    Apego Actualizado: Febrero 2010 Editor del Tema : Marinus van IJzendoorn, PhD, Leiden University, Países Bajos Índice de contenidos Síntesis 5 Impacto del Apego a la Madre y al Padre durante los Primeros Años, en el Desarrollo 8 Psicosocial de los Niños hasta la Adultez Temprana KARIN GROSSMANN, PHD., KLAUS E. GROSSMANN, PHD., AGOSTO 2007 Desorganización de las Estrategias de Apego en la Infancia y la Niñez 15 KATE HENNIGHAUSEN, PHD., KARLEN LYONS-RUTH, PHD., JUNIO 2007 El Apego durante los Primeros Años (0-5) y su Impacto en el Desarrollo Infantil 20 MARINUS VAN IJZENDOORN, PHD., MAYO 2005 El Apego en la Primera Infancia: Comentarios de van IJzendoorn y Grossmann y 24 Grossman GREG MORAN, PHD., JULIO 2005 El Apego y su Impacto en el Desarrollo Infantil: Comentarios de van IJzendoorn, 27 Grossmann y Grossmann , y Hennighausen y Lyons-Ruth CHARLES H. ZEANAH JR., MD, PRACHI SHAH, MD, JULIO 2005 El Impacto de las Intervenciones Basadas en el Apego, sobre la Calidad del Apego entre 32 Lactantes y Niños Pequeños MARY DOZIER, PHD., KRISTIN BERNARD, M.A., DICIEMBRE 2004 Programas de Intervención y Prevención para Niños Pequeños, Basados en el Apego 36 BYRON EGELAND, PHD., DICIEMBRE 2004 Eficacia de las Intervenciones Basadas en el Apego 42 DIANE BENOIT, MD, FRCPC, ABRIL 2005 Intervenciones Basadas en el Apego: Comentarios sobre Dozier, Egeland y Benoit 46 SHEREE L. TOTH, PHD., ABRIL 2005 ©2004-2017 CEECD / SKC-ECD | APEGO 2 Apoyando a las Familias para Construir Relaciones de Apego Seguro: Comentarios sobre 50 Benoit, Dozier y Egeland FEMMIE JUFFER, PHD., MARIAN J. BAKERMANS-KRANENBURG, PHD., Y MARINUS H.